SCCM Resource Library-42-Validation of the Patient Dignity Inventory to Assess Dignity-Related Distress in the Critically Ill

Video Transcription

Hi, I'm Blake Merkler, a current anesthesiology resident at the University of Pennsylvania.  And today I'm here to discuss validation of the patient dignity inventory to assess patient dignity-related distress in the critically ill.  I have no disclosures for this presentation. Prior research has demonstrated that patients discharged from the ICU are at risk of experiencing  significant cognitive and psychological issues. Furthermore, depression following critical illness is associated with increased risk of mortality within two years of discharge.  This begs the question if adoption and implementation of tools in critically ill patients while in the ICU have the potential to improve short-term post-ICU well-being.  Our research group recognized that the impact of dignity-centered care had not been systematically studied in the critical care population.  Thus, in this study, we aim to examine the validity of a tool called the patient dignity inventory in critical care settings in order to better characterize patient distress.  The patient dignity inventory, also known as the PDI, is a 25-item instrument shown here designed to measure sources of dignity-related distress and to gain insight into patient's  emotional, physical, and spiritual well-being. Through this framework, dignity can be used as a construct to help physicians identify patient-centered care objectives.  This tool, originally validated in terminally ill patients, has more recently been extended to various other populations.  As you can see from this slide, it addresses 25 potential problems patients may be experiencing.  For example, feeling that I'm a burden to others, experiencing physically distressing symptoms, not being able to continue with my usual routines, to name just a few.  For each problem, patients are asked to rate the extent on a Likert scale from not a problem  to an overwhelming problem to give providers a better insight into the patient's condition at that point in time.  This study took place in five different ICUs within the University of Pennsylvania health system.  Medical and surgical adult ICU patients with a length of stay of at least 48 hours and without evidence of delirium, dementia, or sedation were approached by research staff.  They were consented and asked to complete the PDI and two additional validated instruments,  including the PHQ-9, the Patient Health Questionnaire 9, to assess depression, and the GAD-7, the Generalized Anxiety Disorder 7, to assess anxiety.  By having these additional surveys, we were able to ascertain the criteria and validity of the PDI.  Other information was also extracted from the electronic medical record, including demographic data and levels of clinical support at time of interview.  463 total patients in the ICU were approached for study participation. 34% of patients consented to participate in the study, with a majority of patients  choosing not to participate due to fatigue, pain, family visiting, or active patient care. Three subjects decided to withdraw during the completion of the surveys, and an additional  two participants skipped some of the questions of the PDI and were excluded. Thus, a total of 155 patients were included in the analysis.  The sample was, by majority, male, white, and married, but as you can see, it did represent the diversity of urban Philadelphia.  The mean ICU length of stay was close to a week at time of interview. Form X-alpha was used to assess the internal consistency of the PDI, and principal components  analysis used to assess the tool's internal structure. Form X-alpha was 0.95, demonstrating the excellent internal consistency of the tool.  Now factor analysis revealed four components identified by our research group. These included, one, illness-related concerns, for example, worry about my future.  Two, interactions with others, for example, the item not feeling supported by friends and family. Three, peace of mind, for example, feeling like I am no longer who I was.  And four, dependency, for example, not being able to attend to my bodily function independently.  While these four factors may seem like somewhat abstract ideas, each factor is a group of items representative of a domain of dignity-related distress.  The factor analysis carried out in our sample was similar to that pursued in other patient populations in prior studies, which found four or five factors with similar groupings  of items. In addition, correlational analysis was carried out to assess criterion validity between the factors of the PDI and the PHQ-9 and the GAD-7.  As you can see on this table shown, there are moderate correlations between the factors and metrics of depression and anxiety.  The PHQ-9, again, commonly used to screen depression in the general population, is moderately associated with a patient's illness-related concerns and peace of mind, as shown in the  PDI. In addition, the GAD-7, as a commonly used screening tool for anxiety, is more correlated  with questions related to dependency than the PHQ-9. However, as shown by the correlations only being moderate, patients may answer questions  on the PDI related to dignity itself differently, as these questions are not fully grasped by a patient's level of depression or anxiety.  It can be inferred from this analysis that dignity, in its essence, represents a related  but unique concept that should be embedded in the realm of critical care. Dignity as assessed by the PDI may reveal psychological states unrevealed by other tools.  Overall, the PDI is a unique validated tool to assess patients' dignity-related distress in the ICU. However, you may be questioning, what could be the impact of this?  Well, led by Dr. Harvey Chochanoff, who originally validated the PDI, there are tools and trainings to implement what his group points as dignity in care.  This is based on 15 years of study led by Dr. Chochanoff in the Manitoba Palliative Care Research Union, in collaboration with progressive researchers from Australia, England,  and the United States. In this study, introducing and validating the PDI in the ICU, there may be a role of dignity-based assessments and interventions in the ICU.  This would be to treat and prevent the psychological symptoms that patients face during and after their ICU stays.  So I know I said a lot, but the main points I want you to take away from this are, the PDI is an instrument designed to measure dignity-related distress.  And with four components identified in this analysis, this study demonstrates that the PDI can be used to assess dignity-related distress in critically ill patients.  Dignity in the ICU is an independent construct, yet it is shown to be associated with patients' levels of anxiety and depression.  And further research may elucidate the role of dignity-based interventions in treating and preventing post-intensive care psychological symptoms.  These are my references for your review. Thank you so much for your attention and listening, and thank you so much to my collaborators as well.

Video Summary

The speaker discussed the validation of the patient dignity inventory (PDI) to assess dignity-related distress in critically ill patients. Previous research has shown that ICU patients are at risk of experiencing cognitive and psychological issues, and depression following critical illness is associated with increased mortality risk. The PDI is a 25-item instrument to measure sources of dignity-related distress and gain insight into patients' well-being. The study validated the PDI in five ICUs and found it to have excellent internal consistency. It also demonstrated moderate correlations between the PDI factors and depression and anxiety metrics. The PDI could be used to assess and address patient distress in the ICU.

Asset Subtitle

Patient and Family Support, Behavioral Health and Well Being, 2021

Asset Caption

The Society of Critical Care Medicine's Critical Care Congress features internationally renowned faculty and content sessions highlighting the most up-to-date, evidence-based developments in critical care medicine. This is a presentation from the 2021 Critical Care Congress held virtually from January 31-February 12, 2021.

Blake D. Mergler

Introduction/Hypothesis: Critical illness confers significant risk of psychological distress both during and after intensive care unit (ICU) admission. The Patient Dignity Inventory (PDI) is a 25-item instrument initially designed to measure psychosocial, existential and symptom-related distress in terminally ill patients, and subsequently validated in oncology, palliative care and psychiatry domains. This study was conducted to validate the PDI as a means of identifying distress in inpatient critical care settings.

Methods: We conducted a single-center prospective cohort study of patients admitted to five different ICUs in two hospitals within the University of Pennsylvania Health System from January 2019 to February 2020. The PDI was administered to adult patients admitted to ICUs for greater than 48 hours. To examine the instrument's construct, content and concurrent validity, patients also completed the Patient Health Questionnaire-9, the Generalized Anxiety Disorder-7, and the Health Care Climate Questionnaire. Demographic data and levels of physiologic support at time of interview were abstracted from medical records. The tool's internal structure was assessed via principal components analysis.

Results: 463 patients were eligible to participate during the enrollment period; 155 (33%) participants consented, completed the surveys and were included for analysis. Mean length of ICU admission at the time of interview was 160 hours. Admitting diagnoses included acute hypoxic respiratory failure, traumatic fall, or heart failure requiring heart transplant. Our study demonstrated internal consistency (Cronbach's Î± = 0.946) of the PDI in critical care settings. Moreover, factor analysis elucidated four themes prevalent in critically-ill patients: illness-related concerns (e.g. 'worry about my future'), interactions with others (e.g. 'not feeling supported by friends and family'), peace of mind (e.g. 'feeling like I am no longer who I was') and dependency (e.g. 'not being able to attend to my bodily functions independently').

Conclusions: This study demonstrates that the PDI can be used to assess patient distress in critical care settings. Further research may elucidate the role of dignity-based interventions in treating and preventing post-intensive care psychological symptoms.

Meta Tag

Content Type Presentation

Knowledge Area Patient and Family Support

Knowledge Area Behavioral Health and Well Being

Knowledge Level Foundational

Knowledge Level Intermediate

Knowledge Level Advanced

Membership Level Select

Tag Mood and Anxiety Disorders

Tag Communication

Year 2021

Keywords

patient dignity inventory

dignity-related distress

ICU patients

depression

mortality risk

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